Medical coding is the process of assigning a code that uniquely identifies a diagnosis or procedure. Proper medical coding is almost always required before a request for reimbursement (e.g., an insurance claim) will be approved by a payer (e.g., a health insurance company). There are often pre-claim documents that must be submitted in order to support a request for reimbursement and require proper medical coding before being accepted by the payer. Examples of such pre-claim documents are notices of admission, prior authorization requests for health care services, referrals, and the like. Additionally, proper medical coding may provide more complete or accurate information in other applications, such as medical necessity inquiries.
Medical coding is usually manually performed by specialized personnel having a significant amount of training, education, experience, and knowledge of the various medical coding systems used and payer requirements. Medical coders review medical records and select appropriate medical codes from medical coding systems. In many cases, medical coding does not occur until after a patient encounter ends (i.e., after the patient checks out) when a request for reimbursement is being prepared for submission to a payer. While skilled at what they do, other health care workers (e.g., admissions and scheduling personnel), are not normally expected, nor required, to be proficient medical coders.
Accordingly, medical coding information is not routinely available when pre-claim communications with the payer should occur, such as when admitting patients, scheduling future appointments/procedures, making referrals, and other activities. For example, the person scheduling a future procedure is more likely than not selecting a visit type (i.e., procedure), such as “MRI of the chest,” without selecting a specific code from a medical coding system required for a request for reimbursement or supporting pre-claim documents. The diagnosis is typically recorded as a narrative (i.e., free text) description in a note field. The phrasing of the narrative description may vary wildly. For example, abdominal pain might be described using “stomach pain,” “belly ache,” “gastroenteritis,” or other phrases, depending upon who is involved in providing and entering the information. It is not until later when the medical coder sorts out the description that the necessary documentation can be submitted to the payer. The separation between the activity necessitating filing of documentation with a payer and having the medical coding needed to file the documentation introduces delay and opportunities for errors to occur that may result in the health care provider not being reimbursed. It is with respect to these and other considerations that the present disclosure has been made.